Abstract
Prostate cancer (PCa) disproportionately affects African American men, but research evaluating the extent of racial and ethnic disparities across the PCa continuum in equal-access settings remains limited at the national level. The US Department of Veterans Affairs (VA) Veterans Hospital Administration health care system offers a setting of relatively equal access to care in which to assess racial and ethnic disparities in self-identified African American (or Black) veterans and White veterans. To determine the extent of racial and ethnic disparities in the incidence of PCa, clinical stage, and outcomes between African American patients and White patients who received a diagnosis or were treated at a VA hospital. This retrospective cohort study included 7 889 984 veterans undergoing routine care in VA hospitals nationwide from 2005 through 2019 (incidence cohort). The age-adjusted incidence of localized and de novo metastatic PCa was estimated. Treatment response was evaluated, and PCa-specific outcomes were compared between African American veterans and White veterans. Residual disparity in PCa outcome, defined as the leftover racial and ethnic disparity in the outcomes despite equal response to treatment, was estimated. Self-identified African American (or Black) and White race and ethnicity. Time to distant metastasis following PCa diagnosis was the primary outcome. Descriptive analyses were used to compare baseline demographics and clinic characteristics. Multivariable logistic regression was used to evaluate race and ethnicity association with pretreatment clinical variables. Multivariable Cox regression was used to estimate the risk of metastasis. Data from 7 889 984 veterans from the incidence cohort were used to estimate incidence, whereas data from 92 269 veterans with localized PCa were used to assess treatment response. Among 92 269 veterans, African American men (n = 28 802 [31%]) were younger (median [IQR], 63 [58-68] vs 65 [62-71] years) and had higher prostate-specific antigen levels (>20 ng/mL) at the time of diagnosis compared with White men (n = 63 467; [69%]). Consistent with US population-level data, African American veterans displayed a nearly 2-fold greater incidence of localized and de novo metastatic PCa compared with White men across VA centers nationwide. Among veterans screened for PCa, African American men had a 29% increased risk of PCa detection on a diagnostic prostate biopsy compared with White (hazard ratio, 1.29; 95% CI, 1.27-1.31; P < .001). African American men who received definitive primary treatment of PCa experienced a lower risk of metastasis (hazard ratio, 0.89; 95% CI, 0.83-0.95; P < .001). However, African American men who received nondefinitive treatment classified as “other” were more likely to develop metastasis (adjusted hazard ratio, 1.29; 95% CI, 1.17-1.42; P < .001). Using the actual rate of metastasis from veterans who received definitive primary treatment, a persistent residual metastatic burden for African American men was observed across all National Comprehensive Cancer Network risk groups (low risk, 4 vs 2 per 100 000; intermediate risk, 13 vs 6 per 100 000; high risk, 19 vs 9 per 100 000). This cohort analysis found significant disparities in the incidence of localized and metastatic PCa between African American veterans and White veterans. This increased incidence is a major factor associated with the residual disparity in PCa metastasis observed in African American veterans compared with White veterans despite their nearly equal response to treatment.
Highlights
Men living in the United States who self-identify as African American historically experience an increased burden of prostate cancer (PCa) in terms of incidence of both localized and metastatic disease as well as morbidity and mortality.[1,2] compared with White men, African American men are more likely to receive a diagnosis of PCa and are nearly 2 times more likely to die of PCa.[1]
Consistent with US population-level data, African American veterans displayed a nearly 2-fold greater incidence of localized and de novo metastatic PCa compared with White men across Veterans Affairs (VA) centers nationwide
Among veterans screened for PCa, African American men had a 29% increased risk of PCa detection on a diagnostic prostate biopsy compared with White
Summary
Men living in the United States who self-identify as African American (or as Black but hereinafter referred to as African American) historically experience an increased burden of prostate cancer (PCa) in terms of incidence of both localized and metastatic disease as well as morbidity and mortality.[1,2] compared with White men, African American men are more likely to receive a diagnosis of PCa and are nearly 2 times more likely to die of PCa.[1] the incidence rates of PCa vary from state to state, racial and ethnic disparities are consistently shown across most geographical regions in the US.[1] A major component of these disparities may be explained by socioeconomic status, which reflects access to care.[3] differences in access to care are insufficient to explain the increased incidence of PCa among African American men.[4] Several recent studies have invigorated the debate about whether equal access to care is sufficient to eliminate some, if not all, of the observed racial and ethnic disparities.[5,6,7,8] access to quality care is an essential component for reducing disparities in disease outcomes, it is important to consider that the racial and ethnic disparities observed in PCa are multidimensional and likely span the disease continuum, including incidence, stage at diagnosis, and frequency of adverse pathological features.[1,9,10] In addition, the use of overall survival end points in the evaluation of PCa disparities often does not capture the full spectrum of PCa morbidity in the African American population[11] because length of life does not consider quality of life, which is frequently adversely affected by disease and treatment.[12] distant metastasis, which is strongly correlated with PCa morbidity and mortality, may represent a meaningful variable to capture the broader burden of PCa for African American men vs White men, in addition to overall survival.[11,13]
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